M. M. Dua1, D. Worhunsky1, R. Rumma1, T. Tran1, K. Hwa1, G. Poultsides1, J. Norton1, B. Visser1 1Stanford University School Of Medicine,Surgery,Stanford, CA, USA
Introduction: The management of acute pancreatitis (AP) has evolved through enhanced understanding of the pathophysiology and natural history of disease. Practice guidelines have emerged to address the issues of antibiotics (abx), nutrition, timing and/or need of intervention for local complications including pancreatic pseudocyst/necrosis. Despite these evidence-based recommendations, our hypothesis is that many hospitals still adhere to historical treatment practices despite the absence of clinical data.
Methods: Patients (pts) transferred to our institution with AP from 2010-14 were retrospectively studied. Pt charts, radiology reports, and procedure notes were reviewed to compare pre- vs post-transfer adherence to guidelines for the management of AP. Primary measures examined (that do not reflect current guidelines) included use of empiric abx, absence of enteral nutrition, drainage of pseudocysts, and intervention for pancreatic necrosis in the early phase (<4wks).
Results: Seventy-eight pts with AP were transferred to our institution from local community hospitals. Outside length of stay (LOS) was 9 (1-52) dys. Etiology of AP primarily included biliary 46%, alcoholic 17%, idiopathic 19%, and hypertriglyceridemia 11.5%; half of the cohort had a previous admission for AP. The admitting service was surgery (49%) or medicine (51%) with 17 pts admitted to the ICU. Pre-transfer, antibiotics (abx) were given to 51 pts; post-transfer, they were discontinued in 33 pts and started in 6 pts within 24hrs of admission (abx use pre vs post, 51 vs 24, p<0.001). Empiric abx for AP without evidence of infection was used in 36 pts pre- versus 9 pts (7 medicine; 2 surgery) post-transfer (p<0.001). Pts were NPO or on TPN in 89% of the cohort; this was reduced to 17% within 72hrs by starting oral diet or enteric feeds (enteral nutrition pre vs post, 9 vs 65 pts, p<0.001). Fifteen pts were transferred for a CT report of non-infected pseudocyst that "required" drainage; two pts had drains needing revision and 5 pts ultimately required intervention after transfer but were treated >4wks from initial episode of AP. Pre-transfer, 5 pts had debridement without evidence of infection (4 of these in early phase) which resulted in prolonged LOS (>21 dys) after transfer.
Conclusion: This study suggests that there is still great confusion in the treatment of AP in community hospitals. Primary principles in the care of these pts are not routinely followed despite established guidelines. Prophylactic abx are not recommended and enteral nutrition is encouraged to prevent infectious complications. Asymptomatic pseudocyst/necrosis do not warrant intervention; with superimposed infection, drainage or debridement should be delayed to >4wks. Increased dissemination of these guidelines is required to prevent lengthy hospitalizations and long term morbidity.